Systems thinking is increasingly being used to address complex public health problems, such as obesity and addiction, which do not easily fit within traditional, more linear approaches. The applications of systems thinking to public health are the subject of a new open-access, quarterly, online journal published by the Sax Institute.
Systems thinking in public health was also the subject of a recent seminar at the Centre for Excellence in Intervention and Prevention Science (CEIPs) which brought together policy makers, researchers and practitioners to hear distinguished health researcher Diane Finegood speak on Solving Complex Problems: Adaptation vs Attribution.
Rebecca Zosel, Public Health Practitioner and Consultant, wrote up a report of the seminar for the CEIPs blog which is reproduced here with permission. She writes:
Diane Finegood, President and CEO of the Michael Smith Foundation for Health Research in Canada, challenged the audience to think differently about solving complex public health issues such as obesity. Central to Diane’s presentation was her stance that health research needed two paradigm shifts: 1) a shift in frame from complicated to complex, and 2) a shift in research systems from attribution to adaptation.
Diane is a strong advocate for a complex systems approach to prevention, an approach that underpins the work of CEIPS and the prevention system in Victoria. The defining and differentiating characteristics of simple and complex systems are provided in Diane’s table below.
| Simple or complicated systems | Complex systems |
| Homogenous | Heterogeneous |
| Linear | Nonlinear |
| Deterministic | Stochastic |
| Static | Dynamic |
| Independent | Interdependent |
| No feedback | Feedback |
| Not adaptive or self-organizing | Adaptive and self-organizing |
| No connection between levels or systems | Emergence |
The characteristics of complex systems match up closely with those of public health practice: comprehensive, dynamic, contextual, and often involving a complex web of multi-faceted and multi-level problems and interventions. A systems approach however is adaptive. This differs from the dominant ‘business model’ of public health, which is to test and pilot interventions on a small scale, and then upscale those proven to be effective and efficient. In contrast, an adaptive systems approach moves away from standardised interventions (i.e. models, guidelines, frameworks) which often don’t allow for local adaptation. Instead it is a truly flexible approach that responds to the complexity and localised influences of people’s lives. This approach elevates the ‘art’ of public health practice. It allows for practitioners to exercise agency and be creative –not just tinker around the edges. The rise of systems thinking in public health signifies a move away from a ‘one size fits all’ approach. As a research participant in my Master of Public Health research eloquently stated earlier this year, “The day of scalability, of standardised programs is dead.”
There appears to be different interpretations about systems approaches, and how they differ from and intersect with other public health concepts (i.e. social determinants of health, capacity building, community development). It is critical that we find a way to describe systems thinking that resonates with policy makers, researchers and practitioners alike. This will help all of us working in public health to buy into systems thinking, and also to sell it to funders. Like all large-scale change, a systems approach to prevention requires long-term commitment and investment. Building workforce capacity and partnership working are also essential.
Diane discussed a suite of solutions for solving complex problems including:
- A reductionist paradigm is not that helpful
- Move from attribution to adaptation
- Support individuals / individuals matter
- Match capacity to complexity
- Set functional goals
- Assess effectiveness
- Build shared measurement platforms
- Distribute decision, action & authority
- Establish networks and teams
- Build authentic trust
- Utilize the relationship between cooperation and competition
- Act locally, connect regionally and learn globally
- “Help it” happen rather than “make it” or “let it” happen.
In arguing for a move from attribution to adaptation, Diane provocatively questioned the value placed on generalizable knowledge and finding one common truth. Despite the apparent consensus amongst participants on the value of adaptation, there was some resistance to embracing it in its entirety. For instance, the importance of parameters for accountability and of government’s ‘command and control’ role (i.e. tobacco control legislation) was highlighted. And as one of the audience asked, if we only go for adaptation then aren’t we reinventing community development all over again?
Perhaps it is possible to view attribution and adaptation on a continuum, alongside other areas in public health: prevention vs. treatment, personal vs. societal responsibility, high risk vs. whole of population, public vs. private sector – the list goes on!
In the current volatile political environment where prevention has fluctuating commitment, it is worth remembering Charles Darwin’s words: It is not the strongest or the most intelligent who will survive but those who can best manage change (i.e. adapt).
One needs to be careful when using the term tochastic. If there were factors not acting within the deterministic framework of Science, then nothing would be determined. This is because non-deterministic causes could cause changes which meant nothing was guaranteed to be determined.
There needs to be a clear distinction made between determinism per se and the probability statistics we use for complex situations where we’re not able to include ALL the contributing elements.